Diagnostic Dilemma: Infective Endocarditis in the Setting of an Esophageal Abscess.

Transesophageal echocardiography (TEE) is the preferred imaging modality to diagnose infective endocarditis (IE). However, esophageal disease can preclude performing a TEE. We present such a scenario. A patient with an esophageal abscess, methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, and septic pulmonary emboli with suspicion for IE based on the modified Duke criteria. However, due to the patient's esophageal abscess, TEE could not be performed safely. We present this case to demonstrate a rare scenario in which a patient with an esophageal abscess also had presumed IE.

Catastrophic Antiphospholipid Syndrome: A Rare Cause of Acute Heart Failure.

Catastrophic antiphospholipid syndrome (CAPS) is a rare variant of antiphospholipid syndrome (APLS). CAPS is a syndrome characterized by microvascular thrombosis leading to multi-organ failure, including acute heart failure. Diagnosis is challenging, and disease progression is rapid. Treatment includes triple therapy with anticoagulation, glucocorticoids, and plasma exchange. We present a case of a patient with CAPS who developed de novo acute heart failure. With treatment, the patient's multi-organ failure improved, including cardiac function. It is our goal to present this case in order to facilitate greater diagnostic suspicion and the early treatment of CAPS to reduce morbidity and mortality.

Acute Liver Failure Secondary to Pyogenic Hepatic Abscess.

Hepatic abscesses are rare and can be pyogenic or amebic. Pyogenic hepatic abscesses are treated with antibiotics, percutaneous drainage when larger than 5 cm, and rarely requires surgical treatment. Clinical and laboratory manifestations of pyogenic hepatic abscesses include fever, abdominal pain, and elevations in liver enzymes. There is little documentation that a pyogenic hepatic abscess can cause acute liver failure. We present a case of a patient who developed acute liver failure secondary to a 14 cm pyogenic liver abscess. The patient's hepatic function normalized with percutaneous drain placement and antibiotics.

Primary Cardiac Angiosarcoma Presenting as Cardiac Tamponade.

Malignant primary cardiac tumors are rare. The most common presenting symptom is dyspnea, which is non-specific. These tumors pose a significant diagnostic challenge, which when coupled with rapid disease progression can result in significant morbidity and mortality. Appearance of cardiac masses on CT and echocardiography can be non-specific. Cardiac MRI can help delineate cardiac tumors but definitive diagnosis requires mediastinal exploration and biopsy. Treatment includes radical resection followed by radiotherapy and chemotherapy along with targeted therapy. Metastasis often precludes candidacy for surgery, therefore, early diagnosis is pivotal. We present a patient with primary cardiac angiosarcoma who initially presented with cardiac tamponade and at time of diagnosis was not a surgical candidate. We aim to bring greater awareness to malignant primary cardiac tumors in hopes of increasing diagnostic suspicion to facilitate earlier diagnosis and treatment intervention.

Metastatic Jejunal Renal Cell Carcinoma Intussusception Presenting as Melena.

Renal cell carcinoma (RCC) most commonly metastasizes to the lungs, and it is uncommon for RCC to metastasize to the small bowel. Small bowel metastasis commonly presents with gastrointestinal (GI) bleeding. In rare cases, a metastatic small bowel mass can serve as a lead point for intussusception. In this report, we present the case of a male patient whose chief complaint was melena. The patient denied any abdominal pain or nausea. Investigation with push enteroscopy revealed a jejunal mass, and further evaluation with CT showed small bowel intussusception. The patient subsequently underwent small bowel resection and anastomosis. Histopathology confirmed that the jejunal mass was metastatic RCC. We present this case in order to showcase the utility of push enteroscopy in the diagnosis of small bowel metastasis in RCC.

Lamotrigine-Induced Acute Pancreatitis.

Drug-induced pancreatitis is a rare phenomenon. Therefore, diagnosis requires ruling out more common etiologies of acute pancreatitis. The majority of research on drug-induced pancreatitis is from case reports. Only a limited number of drugs have been definitively established to induce pancreatitis. Lamotrigine is used in both bipolar and epilepsy. Lamotrigine is currently weakly identified to induce pancreatitis. We present a case of lamotrigine-induced pancreatitis. Extensive workup ruled out other major causes of pancreatitis-including alcohol. We aimed to show lamotrigine can be a causative drug of acute pancreatitis.

Quinine Water-Triggered Atrial Tachyarrhythmia.

Quinine is an anti-malarial drug with documented hematologic, dermatologic, and cardiovascular side effects. Tonic water contains a sub-therapeutic amount of quinine and is available over the counter. However, the public is unaware of the risks associated with excessive consumption of tonic water. We present a patient who developed atrial flutter with a rapid ventricular response following the consumption of tonic water. The patient responded to rate control therapy and was discharged the following day with a plan to follow up in the outpatient department with an electrophysiologist. Although quinine has been shown to have ventricular anti-arrhythmic effects, its effect on the atria has not been determined. We present this case to bring greater awareness to the cardiovascular risks associated with the consumption of tonic water to reduce morbidity and mortality.